A premature baby died due to mistakes made by medical staff from two of the UK’s worst hospital trusts, an inquest heard.
George French-Russell passed away 12 days after he was delivered on the landing on his parents home in Buxton, Derbyshire by panicked paramedics.
The newborn, who was born in breach, was starved of oxygen in the crucial first few minutes of his life which caused devastating brain damage.
Expecting mother Katie French, 26, told the coroner: ‘It felt like I was delivering the baby on my own.’
Grant French-Russell, pictured above with parents Brendan and Katie, passed away 12 days after he was delivered on the landing on his parents home in Buxton, Derbyshire by panicked paramedics
The grieving parent, who was forced to switch off George’s life support, described the chaotic labour to Stockport Coroner’s Court this week for an inquest into her son’s death.
An inquest revealed a catalogue of mistakes which saw:
- High-risk Miss French’s 30 week scan cancelled because staff were on leave
- Miss French advised by unqualified midwife assistant after calling up in agony
- East Midlands Ambulance arrive eight minutes late after Miss French called 999
- Paramedics request for midwife or doctor to be sent to scene ignored
- Doctor advising paramedic on the phone allegedly end the call before birth
- Pre-longed birth cause Grant to be starved of oxygen and cause brain damage
The court was told how George was a ‘much wanted baby’, by parents Miss French and Brendan Russell, 41, who were excited for his arrival.
Miss French had been previously identified as a ‘high risk pregnancy’ but was positive as scans showed the baby was developing well.
The cook told the hearing: ‘I could feel him kick all the time, moving about and I heard his heartbeat. He was just perfect.
‘At 20 weeks they told me he was breech, but they said not to worry as he had plenty of time to turn’.
Her next ante-natal clinic was cancelled because the NHS consultant was on leave and no replacement was available, so a planned scan did not take place.
She said: ‘I then had an appointment in early January and I saw the midwife, she said everything was fine.’
Devastated: Miss French and Mr Russell, pictured together above, told the court they felt let down by the care and advice given by the NHS
But tragically the inquest heard how the family’s ordeal began on January 11 last year after Miss French woke up in pain after going into labour early.
She was told by an unqualified assistant to take two paracetomol.
The young mum said the pain got worse, so she rang partner Brendan at work and he rushed home.
But rather than ring the hospital back she called the community midwife team based just two miles down the road. No one was available to speak.
It was another 30 minutes before they called back and made an appointment for her to visit the unit later that afternoon. But then she started bleeding heavily.
Frantically she dialled 999 and East Midlands Ambulance Service dispatched a crew. She told the call handler she was having contractions.
The ambulance should have been with her within eight minutes, it took more than double that time. Full details of the unfolding emergency were not properly relayed to the crew.
Paramedic Anthony Herritt said he requested a midwife but was told to instead move Katie to the hospital, which was not feasible as it was more than 30 minutes away.
He said Dr Raid Hamoudi advised him over the phone to carry out an internal examination.
Speaking in court, he said: ‘He told me I was going to have to do it, then I managed to release the other foot.
‘It was a very short call and I wasn’t happy about it being ended. It was one of those situations when you have an expert on the phone you want all the advice you can get.’
Dr Hamoudi denied that he was uninterested or rushed to get off the phone. He claimed the paramedic ended the call after the baby had arrived.
South Manchester Senior Coroner Alison Mutch questioned why the doctor had shown a lack of interest in the outcome and why paramedics had not made further efforts to seek expert assistance.
Giving her evidence Miss French said: ‘It felt like I was delivering the baby on my own.’
Another ambulance arrived George and was delivered weighing in at 5lbs 5oz. Crucially it was 25 minutes after his foot first appeared and 15 minutes after the call with the doctor ended.
It was only then two community midwives, who had been alerted to the emergency, arrived at the house to help the baby who appeared ‘floppy and pale’.
Both mother and child were rushed to Stepping Hill. Later that day the infant was transferred to a specialist unit at The Royal Bolton Hospital, but it soon became clear he had suffered serious brain damage due to a lack of oxygen during the prolonged birth.
It just killed me. I didn’t want to do it, but we couldn’t let him suffer
After 12 days doctors gave his parents the news that his condition was unlikely to improve, and they took the heartbreaking decision to withdraw life support on January 23.
‘It just killed me. I didn’t want to do it, but we couldn’t let him suffer,’ sobbed Miss French.
Giving a narrative conclusion Ms Mutch said: ‘Baby George died from a recognised complication of footling breech, contributed by the absence of expert advice during the delivery.’
She said she was troubled by the way information had been exchanged and that some calls and conversations were poorly documented. She also urged the hospital to make it clear the triage number is the only one to be used in such incidents to avoid any repeat.
Last night a grieving relative said: ‘The men and women of the NHS are, on the whole, wonderful people. But on this occasion, they have failed us terribly.’
At the end of the three-day hearing George’s grandfather Wayne Russell said: ‘The inquest was open and thorough and on the whole we are satisfied.
‘But there are no winners in these matters. We’ve lost a son and a grandson who would just have celebrated his first birthday.
‘It gives us no pleasure to see NHS staff brought before a court to see how they made such horrendous mistakes.’
The inquest heard the closure of the town’s maternity unit in July 2012 as part of a £3 million cost cutting exercise left pregnant women under the care of Stepping Hill Hospital 16 miles away in Stockport, Greater Manchester.
The coroner heard how at the time of George’s death last year the maternity department was short of six staff, while community midwives based locally had heavy caseloads.
A senior midwife told the coroner there was a shortage of maternity experts at the hospital but they ‘just had to cope’.
It gives us no pleasure to see NHS staff brought before a court to see how they made such horrendous mistakes
Both EMAS and Stepping Hill claimed steps have been taken to improve the way cases are handled and information shared since the tragedy.
In 2016 the hospital was ordered to improve by the Care Quality Commission (CQC), but when inspectors returned last year they said standards had dropped even further.
The health watchdog warned Stockport NHS Foundation Trust, which runs the hospital, of patient care being ‘compromised’ by staff shortages.
A Trust spokeswoman said: ‘This was a very tragic case and our sympathies are with George’s parents and family. His delivery was very difficult and followed an unexpected course.
‘The advice that was provided to George’s mum on the day of his delivery was clinically appropriate. The coroner made no findings in relation to staffing levels or their role in George’s death.’
Dr Bob Winter, Medical Director of EMAS said: ‘Our ambulance crews are highly trained and experienced however, they are not maternity experts and rely on other healthcare professionals to support them.
‘After this incident we proactively reviewed our response to this emergency. We will consider recommendations made by the coroner.’